Redefining death, again

Suppose you are in a terrible accident. Doctors have determined that your chances of survival are basically nil and you're on life support, but your heart is still beating and you are not quite "brain dead." Your family, grieving, has decided that you would have wanted the remains of your earthly shell to save someone else's life, if possible, and has authorized doctors to retrieve organs suitable for donation.

Surgeons will shut off your life support systems, wait two minutes to make sure your heart doesn't spontaneously revive, and then start to cut.

At this point, the chances of you spontaneously reviving in that two minutes, or that doctors have somehow misdiagnosed your fatal condition, are tiny. It has happened, but very rarely; it's not something you should rely on.

Nevertheless, a Washington Post story describing a recommendation from a Richmond, Va.-based agency that oversees organ donation in the United States should raise some serious questions about where all this is headed.

Here's the background: The United Network for Organ Sharing (UNOS) coordinates organ donation under a contract with the federal government. It is proposing guidelines that say doctors no longer need to wait two minutes after a donor's heart stops beating before removing the donated organs.

UNOS "is also poised to eliminate what many consider a central bulwark protecting patients in such already controversial cases: an explicit ban on even considering anyone for those donations before doctors and family members have independently decided to stop trying to save them," according to the Post.

The reaction from the transplant medical community was predictable and delivered via ABC News: "Concerns Over New Donor Guidelines Overblown" was the headline. The Post article was "a hysterical and inappropriate reaction to a very minor change in some standards. There is zero threat to the public well-being in this document," according to ABC source Dr. Jeffrey Punch, chief of the section of transplantation at the University of Michigan's Department of Surgery. Hospitals set their own policy for such questions, added another source. Nothing to see here, folks. Move along.

ABC's sources worried that the Post article would frighten people away from signing up as organ donors and exacerbate a decades-long organ shortage, one that's existed since transplantation became medically viable. Organ transplants extend the lives of thousands of Americans annually, but about 6,000 people per year die waiting for one.

Lost in the debate is the fact that for four decades doctors have been, as one medical ethicist puts it, "gerrymandering" the definition of death to allow doctors to start "harvesting" organs at an ever-earlier stage without violating the self-explanatory "dead donor rule."

At one time it was easy to diagnose "death": no heartbeat, no breath, cooling, blue, and stiff. But organs from such corpses have usually degenerated too much to be transplantable, so when transplant technology became widespread in the 1960s the first thing doctors had to do was redefine "death."

First, in the 1970s, it was enough to be "brain dead." Then in the 1990s, the organ donation community embraced "donation after cardiac death," or what was described above: Your brain may still be functioning, but your prognosis is so poor that doctors and your family agree to take you off life-support and let your heart stop beating, then they harvest the organs.

Now UNOS wants the public to accept the wonderfully euphemistic "donation after circulatory death" so surgeons don't to have to wait that two minutes. This tacitly acknowledges that those hearts they were cutting out of donors obviously weren't really quite "dead" if they could be transplanted into somebody else.

Where, exactly, will this end? How soon after you hit the emergency room will nurses start eyeing you as a potential donor? Could we ever get to the place where the ethics of organ donation are reversed? Where, to prevent the damage that occurs to organs when the flow of blood and oxygen is cut off, it one day becomes unethical to take organs from people who aren't at least a little bit alive? When the donation criterion becomes consent instead of death? Do we want hospitals where the rule of thumb is, "Mostly dead, plus consent, and you're good to go"?

We're nowhere near anything like that, transplant doctors protest today. I agree. My driver's license indicates I'm an organ donor and I have no intention of changing that. People should sign up to be organ donors.

The problem is that doctors don't decide what's ethical and do that; rather, if enough doctors start doing it, eventually they agree it's ethical. Look at how abortion went from unthinkable to unimpeachable in a generation. Consider how the taboo against physician-assisted suicide has eroded in the last 20 years.

Later generations might well wish we'd had a frank and open discussion about this issue while we still had a chance.

For a lengthier and satirical look at where this issue might be headed, read this Salvo Magazine essay from a few years back.